Health History
Please complete the below form
Name
First Name
Last Name
Birth Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Female
Male
Other
Address
Street Address
Street Address Line 2
City
State
Postcode
Cell Number
Please enter a valid phone number.
Format: 000 000 0000.
Email
example@example.com
Emergency Contact
Number
Please enter a valid phone number.
Format: 000 000 0000.
Prescription Medication
Over the counter medication/supplements (vitamins, minerals, herbs, etc)
Are you currently
Pregnant
Please Select
Yes
No
Unsure
Comment
Breastfeeding
Please Select
Yes
No
Unsure
Comment
Have and allergy or sensitivity to vitamins or medications?
Please Select
Yes
No
Unsure
Comment
Recent hospitalization, surgery, cancer or major illness?
Please Select
Yes
No
Unsure
Comment
Kidney disease, reduced kidney function?
Please Select
Yes
No
Unsure
Comment
Heart disease or fluid restrictions?
Please Select
Yes
No
Unsure
Comment
History of fainting with needles?
Please Select
Yes
No
Unsure
Comment
Any reason you cannot take NSAIDS?
Please Select
Yes
No
Unsure
Comment
Fever, infection or feeling acutely unwell?
Please Select
Yes
No
Unsure
Comment
Recent lifestyle factors
Recent intense exercise
Recent travel
High stress
Medical History
High blood pressure
Heart condition
Thyroid disorder
Diabetes
Migraine Disorder
Anxiety or panic history
Autoimmune condition
Cancer or working with oncology
None of the above
Treatment Understanding
I understand IV and IM wellness therapies are elective wellness services
I understand my treatment will be personalized after clinical assessment
I agree to inform staff of any health changes and confirm all information entered is correct.
At Concierge IV, intravenous hydration and intramuscular wellness injections are elective services designed to support hydration, nutrient replenishment, recovery, and overall wellness.I understand that IV and IM therapies involve placement of a needle into a vein or muscle and may include administration of fluids, vitamins, minerals, amino acids, or medications as clinically appropriate.I understand that possible side effects may include, but are not limited to:Bruising or soreness at the injection siteLightheadedness or faintingNauseaInfection or inflammation at the siteAllergic or medication reactionFluid overload or changes in blood pressureI understand that treatment benefits are not guaranteed and that responses to wellness therapies may vary.I confirm that I have disclosed my medical history, medications, allergies, and any current symptoms to the best of my knowledge. I agree to inform the clinical team of any changes in my health status prior to treatment.I understand that a clinical assessment, including a Good Faith Exam when required, will be completed prior to treatment and that services may be modified or deferred based on medical judgment.I understand that I may stop treatment at any time and may ask questions before, during, or after my visit.IV hydration, intramuscular wellness injections, and red light therapy at Concierge IV are elective services designed to support how you feel, recover, and recharge.These treatments may involve a small needle for IV or IM therapy or exposure to therapeutic light. Possible side effects can include temporary soreness, bruising, lightheadedness, nausea, skin sensitivity, redness, or rare allergic or blood pressure changes.Results vary from person to person. I confirm I have shared my health history and understand a clinical assessment, including a Good Faith Exam when needed, will be completed before treatment.I understand I can pause or stop services at any time.By continuing, I voluntarily consent to receive wellness services at Concierge IV.
Signature
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Submit
Submit
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